Run, hide, fight: Responding to an active shooter

More deadly mass shootings occurred in the United States in 2013 than in the 1960s and 1970s combined. Yet despite the unprecedented increase in gun violence, such incidents remain relatively rare.

"You're more likely to be struck by lightning than die in a work-related shooting," says John Hick, M.D., an emergency physician at Hennepin County Medical Center (HCMC) and medical director for emergency preparedness there. "But while we all know the basics of how to avoid lightning, we know far less about workplace violence and what to do if we're confronted by someone with a weapon. Unfortunately, this is an issue we need to address."

Dr. Hick isn't alone in his concern. Lessons learned from the Columbine, Aurora and Sandy Hook tragedies have caused a nationwide re-examination of the way individuals, institutions and public safety officers prepare for and respond to active shooter events.

Mass shootings are volatile and complex situations requiring extraordinary planning, coordination and cooperation among various agencies that often have different approaches and points of view. In addition, developing protocols for hospitals carries the added burden of ethical and moral considerations, says Matthew D. Sztajnkrycer, M.D., Ph.D., an emergency physician at Mayo Clinic's Level I Trauma Center in Rochester, Minnesota, and a disaster medicine specialist.

"The problem is that there are no one-size-fits-all answers for these questions. No one can tell us how we should or will act under these circumstances. The general concept of 'run, hide, fight' is a good one. The best thing to do, really, is to empower everyone to do what they feel most comfortable doing, without fear of subsequent repercussions or recriminations," he says.

Dr. Hick, too, applauds "run, hide, fight"— a concept promoted by the city of Houston in a six-minute video that's mandatory viewing for all incoming residents at the HCMC.

The video describes three options for surviving an attacker:

If a safe path is available, run to a safe place and help others out, too.

If it's not possible to get out safely or you're not sure it's safe, find a place to hide. Lock the door, barricade it and silence your cellphone. Calling 911 or emergency help from a landline can help operators pinpoint your location.

If there is no other option, fight the attacker aggressively, using whatever weapons are available (for example, a pen, fire extinguisher or hot coffee).

Dr. Hick believes hospitals also have an obligation to protect patients. "Everyone should know when to run and when to shelter in place. And the specific actions to protect patients — for instance, moving them into locked bathrooms — should be clearly defined. If you are confronted, you have to protect yourself, but providers may be torn between themselves and patients, so it's helpful to have a policy that is very clear about that," he says.

Dr. Sztajnkrycer notes, however, that active shooters in occupational settings are often current or former employees, making plans about safe rooms and evacuation routes problematic.

Given the many challenges of care under threat, what should hospitals do? "Small hospitals and large hospitals are in the same situation," Dr. Sztajnkrycer says. "They face the same questions and have the same time constraints placed upon them in these events. The best thing to do is simply start the discussions. Hospital, security and law enforcement leadership need to get together in the same room and discuss events. Learn the limitations of each group. Learn about faulty preconceptions. Develop a plan. Try the plan through a tabletop and see what unexpected events pop up. A little upfront discussion can go a long way."

Dr. Hick says HCMC is reappraising its policies for acts of violence, which don't adequately cover active shooter events. The reappraisal has brought many issues to the fore, including the lack of armed security.

"We are working toward policy development, training and exercises," he says. "We want to make sure we have the right things in place and the best policies before undertaking training. That said, we are trying to use public education pieces like the video 'Run. Hide. Fight.' We are saying to people, 'Watch this. It could save your life.' "

The 3 ECHO debate

Research has shown that most active shooter events end within minutes and active risk is often over before first responders arrive on the scene. In the past, however, the approach has been one of extreme caution, which has led to delayed intervention and unnecessary deaths.

Based on these findings, a new pre-hospital paradigm is evolving that more rapidly prioritizes victim access. Called 3 ECHO, which stands for enter, evaluate, evacuate, it has been advocated by the Hartford consensus group, which is composed of many law enforcement and rescue stakeholders. A training program, developed in Minnesota and approved by the Department of Justice, reflects these priorities.

The 3 ECHO training focuses on establishing secure, safe corridors for firefighters and EMS to enter so they can rapidly assess, stabilize and evacuate injured people to a safe area. It's based on the understanding that most people who are shot or injured die of blood loss and that time is of the essence.

These strategies are being implemented in many metropolitan areas, and 3 ECHO is used by most agencies in the Twin Cities. But as Dr. Hick notes, "Hostile events can occur in smaller communities, too, such as the 2005 shooting in Red Lake, Minnesota. Rural communities that don't have as many resources need to plan even more carefully, so they can enter, evaluate and evacuate people from the threatened area as quickly and safely as possible."

Even so, EMS providers worry about the risks posed by 3 ECHO versus the benefits of early rescue. Dr. Sztajnkrycer is sympathetic to these concerns: "I know some express concern about the risks that 3 ECHO may present to their current operational schema, and I respect this. The fundamental tenet of EMS is not to enter an unsafe scene. At the same time, we have to understand that we live in a changed world. We realize that in certain circumstances, the regular rules don't apply.

"Consider the tragedy at Columbine. At the time, law enforcement followed what they believed to be a sound tactical doctrine. They secured a perimeter, waited until SWAT arrived and allowed them to make entry. Now we look back upon those events and shake our heads in disbelief. People were dying. Why did they not enter sooner? And so now, at the law enforcement level, active shooter response is no longer a SWAT operation but a patrol-level response. There is even discussion about single-officer entry. Today, responding to hostile events is simply part of the job."

Dr. Hick adds, "There is a risk that those responding to accidents will be hit by a car, that firefighters entering a burning building to conduct a rescue (with proper training and under the right conditions) may be injured and that an officer may be shot while responding to a domestic assault. No situation is safe, and we will always require assessments that are grounded in training and integrated with our partner agencies."

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